tomy, and the intraoperative cholangiogram was normal. After an uncomplicated postoperative course, the patient was discharged on postoperative day 14. She had no further episodes of bleeding or anemia. The overall complication rate of ERS is probably in the range of 6 to 9%, and there is a reported mortality rate of approximately 1%. This compares favorably with patients treated with surgery.1 The most common of the complications of ERS are bleeding, pancreatitis, and cholangitis. Unusual complications include perforation and entrapment of the stone removal basket. Most complications are apparent in the first 24 hours after the procedure and can be managed without surgery. Silvis and Vennes 2 reported on 122 patients with post-ERS bleeding. Of this group, only 18 required surgery. The mortality among this group was significant, as 11 deaths occurred. The bleeding site was reported as often being difficult to locate at the time of surgery. The bleeding usually emanates from the actual sphincterotomy site or the common bile duct. The decision to treat this patient with gallstone pancreatitis by ERS was influenced by her advanced age and dementia. The procedure, although successful at stone removal, was complicated by traumatic disruption of the right gastroepiploic artery, a complication of ERS that has not been reported. The site of bleeding is not located in the proximity of the actual sphincterotomy site, and the pathogenesis of this type of injury is not known. Perhaps excessive pressure was exerted by the portion of the scope lying within the stomach. The repeated instrumentation of the common bile duct during the attempted stone removal may have been a factor. William H. Risher, MD James W. Smith, MD New Orleans, Louisiana
REFERENCES 1. Neoptolemos JP, Shaw DE, Carr-Locke DL. A multivariate
analysis of preoperative risk factors in patients with common bile duct stones. Ann Surg 1989;209:159-61. 2. Silvis SE, Vennes JA. Endoscopic retrograde sphincterotomy. In: Silvis SE, ed. Therapeutic gastrointestinal endoscopy. New York: Igaku-Shoin, 1986:198-240.
Common hepatic duct perforation: a rare complication associated with ERCP To the Editor: Only one case of common bile duct perforation secondary to ERCP has been reported. 1 Herein, we report a case of a 45-year-old woman who presented with 5 days of right upper quadrant abdominal pain, nausea, fever, and jaundice. She had a history of cholecystectomy and removal of common bile duct stones 12 and 6 years previously. On physical examination, there was moderate to severe pain on palpation of the right upper quadrant of the abdomen and the liver was palpable 12 cm below the right costal margin. The laboratory results were: white blood count, 13,700 cells/mm3 with 41 % bands; total bilirubin, 48 mg/100 ml; direct biliVOLUME 36, NO.4, 1990
Figure 1. Endoscopic retrograde cholangiopancreatogram showing dilation of the common bile duct, stones, and extravasation of contrast (arrows).
rubin, 3.9 mg/100 ml; alkaline phosphatase, 481 units/liter; aspartate aminotransferase, 23 units/liter; alanine aminotransferase, 62 units/liter; amylase, 26 units/liter; and prothrombin time, 13 sec (normal 13 sec). An ultrasonographic examination showed dilation of the common bile duct. An ERCP was performed, which revealed dilation of the common bile duct with multiple calculi and extravasation of contrast material around the common hepatic duct (Fig. 1). During ERCP, the catheter was placed only in the distal common bile duct and stone removal was not attempted. At laparotomy, there was a collection of about 100 ml of bile around the hepatic duct and a 2-cm perforation of the anterior aspect of the common hepatic duct. Several primary stones were removed from the bile ducts and aT-tube was placed into the common hepatic duct through the perforation. The wall of the duct was noted to be markedly friable. A Penrose drain was placed around the duct. In the post-operative period, there was continuous drainage of bile and purulent material through the Penrose drain. A T -tube cholangiogram performed after 10 days revealed residual common bile duct stones and extravasation of contrast material around the T-tube. Two months later, the patient underwent surgical removal of the stones and hepaticojejunostomy. Julio C. U. Coelho, MD, PhD Antonio C. L. Campos, MD, MS Julio C. Pisani, MD Paula M. Salles, MD Adyr A. Moss, Jr., MD Departments of Surgery and Internal Medicine Federal University of Parana Curitiba, Parana, Brazil
REFERENCES 1. Jayaprakash B, Wright R. Common bile duct perforation-an unusual complication of ERCP. Gastroint Endosc 1986;32:2467.
427
REFERENCES 1. Neoptolemos JP, Shaw DE, Carr-Locke DL. A multivariate
analysis of preoperative risk factors in patients with common bile duct stones. Ann Surg 1989;209:159-61. 2. Silvis SE, Vennes JA. Endoscopic retrograde sphincterotomy. In: Silvis SE, ed. Therapeutic gastrointestinal endoscopy. New York: Igaku-Shoin, 1986:198-240.
Common hepatic duct perforation: a rare complication associated with ERCP To the Editor: Only one case of common bile duct perforation secondary to ERCP has been reported. 1 Herein, we report a case of a 45-year-old woman who presented with 5 days of right upper quadrant abdominal pain, nausea, fever, and jaundice. She had a history of cholecystectomy and removal of common bile duct stones 12 and 6 years previously. On physical examination, there was moderate to severe pain on palpation of the right upper quadrant of the abdomen and the liver was palpable 12 cm below the right costal margin. The laboratory results were: white blood count, 13,700 cells/mm3 with 41 % bands; total bilirubin, 48 mg/100 ml; direct biliVOLUME 36, NO.4, 1990
Figure 1. Endoscopic retrograde cholangiopancreatogram showing dilation of the common bile duct, stones, and extravasation of contrast (arrows).
rubin, 3.9 mg/100 ml; alkaline phosphatase, 481 units/liter; aspartate aminotransferase, 23 units/liter; alanine aminotransferase, 62 units/liter; amylase, 26 units/liter; and prothrombin time, 13 sec (normal 13 sec). An ultrasonographic examination showed dilation of the common bile duct. An ERCP was performed, which revealed dilation of the common bile duct with multiple calculi and extravasation of contrast material around the common hepatic duct (Fig. 1). During ERCP, the catheter was placed only in the distal common bile duct and stone removal was not attempted. At laparotomy, there was a collection of about 100 ml of bile around the hepatic duct and a 2-cm perforation of the anterior aspect of the common hepatic duct. Several primary stones were removed from the bile ducts and aT-tube was placed into the common hepatic duct through the perforation. The wall of the duct was noted to be markedly friable. A Penrose drain was placed around the duct. In the post-operative period, there was continuous drainage of bile and purulent material through the Penrose drain. A T -tube cholangiogram performed after 10 days revealed residual common bile duct stones and extravasation of contrast material around the T-tube. Two months later, the patient underwent surgical removal of the stones and hepaticojejunostomy. Julio C. U. Coelho, MD, PhD Antonio C. L. Campos, MD, MS Julio C. Pisani, MD Paula M. Salles, MD Adyr A. Moss, Jr., MD Departments of Surgery and Internal Medicine Federal University of Parana Curitiba, Parana, Brazil
REFERENCES 1. Jayaprakash B, Wright R. Common bile duct perforation-an unusual complication of ERCP. Gastroint Endosc 1986;32:2467.
427
